Investigating the Role and Impact of an Information System in Accrediting and Delivering Breast-screening Services in Tasmania: a Nexus between Accreditation and Practice

This dissertation presents a multi-method research approach for the systematic study of wicked problem domains (Rittel, 1984 [1972]), developed through an investigation of an information system (IS) within a health service organisation, BreastScreen Tasmania (BST). BST is an accredited organisation within a national screening and assessment Progam, BreastScreen Australia. The Program is a population health initiative that also provides multi-disciplinary diagnostic clinical services to individual clients/patients, measured against 176 National Accreditation Standards. The demographic change of ageing population is a crisis that threatens the sustainability of future health services and highlights a role for IS/ICT to deliver work efficiencies. Conflicting perspectives and competing models for assuring the quality and safety of health services assume a role for IS/ICT to provide data processing capabilities to support health service practices and to evaluate health service outcomes. An ‘e-health’ vision assumes that well-integrated information and standardised work practices will result in efficiency, effectiveness, safety and quality. But IS/ICT solutions often fail to accommodate the complexities of information use in health settings. This situation of competing perspectives, opposing forces and health IS/ICT failures indicates that health service delivery into the future is a wicked problem that cannot be easily defined and will not be solved by better IS design. The methodological contribution of this research is a structured process of inquiry that emphasises a human-centred perspective: patient-centred care, human centred computing and human centred research. The dissertation shows how a multi-method approach is systematically conducted, how appreciation of a problem situation for an organisation emerges and is studied over three-phases. Soft Systems Methodology was adopted as the conceptual framework for the research process. Grounded Theory Methodology provided a range of flexible strategies and lenses for qualitative data collection and analysis. A construct, ‘People, place and things’ (PPT), was developed and used as a heuristic device to sensitise the researcher to different units of analysis, techniques and lenses for structuring and modelling data, particularly drawing on Distributed Cognition, Communities of Practice and Activity Theory. Substantively, the research contributes a detailed single case of a health service delivery organisation with wicked problem properties. The investigation focused on the role and impact of a client record (electronic and paper) on two BST activities and their inter-relationships. Firstly, accrediting the delivery of its breast screening and assessment services and secondly supporting decision-making of both individual clinicians and clients/patients. More broadly, it also analysed how the IS impacted on the roles and interactions amongst the professionals working within BST. BST’s -1- Jo-Anne Kelder problem situation was identified as a nexus between accreditation and practice in which two forms of accreditation are in tension. These tensions are embedded in the information system supporting BST activities. BST uses a client information system to measure its performance at organisation level, which can conflict with social forms of accreditation such as professional memberships. This conflict is mirrored by the difference between population-level, evidence-oriented data and the meaning of data in the context of a specific client receiving a health service. Theoretically, the research contributes two conceptual models. Model one highlights that the nexus is embedded in the organisation’s information system and work practice design such that two forms of accreditation are in tension and must be managed. Artefacts used to measure performance construct organisation-level accreditation; individuals are accredited socially via membership. Model two highlights that the client reco